Stimulated by Eucker et al 2024.[1]
ED – emergency department
NC – North Carolina
IF – impact factor
RCT – randomised controlled trial
MSK – musculoskeletal
BFA – battlefield acupuncture
ASP – Aiguille d’acupuncture Semi-Permanente
NRS – numerical rating scale
MCID – minimal clinically important difference
LBP – low back pain
EA – electroacupuncture– key to acronyms
This paper from Duke University, NC, was published online in May, but I seem to have missed it until a linked opinion piece was published last week.[2] Both are in the journal Annals of Emergency Medicine (IF 6.6), which is the official journal of the American College of Emergency Physicians.
It is titled as an adaptive pragmatic RCT and the protocol was published in BMJ Open (IF 2.4) in 2022.[3] Stage 1 of the study was a 3-armed comparative RCT with 1:1:1 allocation to usual ED care (for patients presenting at a convenient time of day with MSK pain) or usual ED care plus one of two different acupuncture interventions (BFA or peripheral acupuncture). This part of the study aimed to find out which acupuncture approach was more acceptable, feasible and effective (n=90, 30 per arm), and then stage 2 was intended to allocate a further 108 patients 1:2 to usual ED care of the more effective acupuncture intervention.
Stage 2 also included outpatient follow-up with 2 sessions of acupuncture per week for a month or no extra treatment for the usual care group. This outcome data is not presented in the paper, so presumable that will be published separately.
In the end, the first stage did not show any difference between the two acupuncture interventions, so all 3 arms continued, but a 1:2:2 allocation was adopted in stage 2. A total of 236 patients were randomised, 38 more than stated in the protocol, presumably because the original planned number would have resulted in insufficient statistical power for 3 arms. All this seems quite reasonable from my perspective.
I have written about BFA here in 2019: Ears and the battlefield. The difference from what is illustrated in that blog and the intervention used in this trial is the needles that were used. The BFA protocol generally uses ASP semi-permanent needles, but here they used the Seirin pyonex needles and the wording (‘…up to 5 bilateral sites’) suggests that not all patients received the full BFA protocol.
The peripheral acupuncture group received needling to sites on the head, neck and limbs according to the clinical discretion of the acupuncturist. The torso abdomen and back were not used. Needle gauge and numbers of points are not described, so the dose is quite hard to assess.
The primary outcome was the change in current pain score (on 0 to 10 NRS) from baseline to 1 hour. It is a little confusing that an NRS was also recorded at ED triage, which was before baseline, and nearly 60% of patients received analgesia prior to baseline as well.
Mean pain scores at baseline were still at 7 or above, although they had started at almost a point higher at triage. The change from baseline to 1 hour was -0.5 in the usual ED care group, -2.1 in the BFA group, and -1.6 in the peripheral acupuncture group. The MCID adopted for this measure in ED was 1.3, so both acupuncture groups exceeded this although if you look at the additional change beyond usual ED care (-1.6 and -1.2) it becomes marginal.
Whilst not significant, BFA seems to be a little in front in these figures; however, when expressed as a percentage change from baseline relative to the usual ED care control, both acupuncture groups have exactly the same figure of 25.4%.
ED analgesia was lowest in the peripheral acupuncture group.
Considering that the largest group (36.9%) had LBP, it seems a shame that the acupuncturists were not allowed to stick a few needles into the erector spinae muscles – something I found very useful when treating acute LBP in the military. Perhaps that was because there was limited space for having these patients lying down.
In a previous trial comparing BFA to EA in MSK pain (n=360), BFA proved to be inferior. I discussed this one here: EA or AA vs UC – the PEACE trial.
References
1 Eucker SA, Glass O, Knisely MR, et al. An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management. Ann Emerg Med. 2024;S0196-0644(24)00161-6. doi: 10.1016/j.annemergmed.2024.03.014
2 Mycyk MB, Seaman L, Yurasek F. Emergency Department Acupuncture Is a Promising Option That Deserves an Open Mind and Continued Rigor. Ann Emerg Med. 2024;S0196-0644(24)00291-9. doi: 10.1016/j.annemergmed.2024.05.023
3 Eucker SA, Glass O, Staton CA, et al. Acupuncture for acute musculoskeletal pain management in the emergency department and continuity clinic: a protocol for an adaptive pragmatic randomised controlled trial. BMJ Open. 2022;12:e061661. doi: 10.1136/bmjopen-2022-061661
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